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Veterans Health Administration

New Treatment Options for Tinnitus Sufferers

In 2010, every VA medical facility audiology clinic received copies of the PTM clinical handbook, counseling guide and hundreds of patient-education workbooks.

The repetitive stutter of a machine gun, shocking boom of mortars, the deafening drone of helicopter rotors; the sounds of war are hard to ignore and can leave many Veterans with permanent hearing damage.

Tinnitus is the number one disability among Veterans and it affects at least one in every 10 American adults.

Some describe ringing sounds, a buzzing sound, a high-pitched whistle, or numerous other sounds. The causes and effects of tinnitus vary from individual to individual, so researchers at the National Center for Rehabilitative Auditory Research approached treatment options the same way.

“Because tinnitus has many causes, many of which are outside the audiology scope of practice, the approach to tinnitus should be interdisciplinary,” explained Dr. Paula Myers, Audiology Section Chief at the Tampa VA Hospital.

“Some of these services are performed by audiologists and some are referred to appropriate professionals. The goal is not to silence tinnitus, because there is no cure. Rather, the goal is for patients to learn to self-manage their reactions to the tinnitus.”

Dr. Myers is a member of the VA research team that developed the Progressive Tinnitus Management (PTM) approach. The culmination of years of studies and clinical trials, PTM evolved into a national management protocol for VA medical centers.

The model is designed to address the needs of all patients who complain about tinnitus, while efficiently utilizing clinical resources. There are five hierarchical levels of management: (1) Triage, (2) Audiologic Evaluation, (3) Group Education, (4) Interdisciplinary Evaluation, and (5) Individualized Support. Throughout the process, patients work with a team of clinicians to create a personalized action plan that will help manage their reactions to tinnitus and make it less of a problem.

“A lot can be done for tinnitus”

“Patients have often been told to go home and learn to live with it, nothing can be done — and it’s really not true. A lot can be done for tinnitus,” said Dr. James Henry, PTM author and Research Professor in Otolaryngology at the Oregon Health & Science University.

Educating patients and providers is a significant element in the PTM approach. For health care providers, the authors of PTM organized a triage procedure to help identify tinnitus patients and access exactly what kind of medical services will best serve their needs. Typically, audiologists coordinate all tinnitus care.

“That’s our front line, when they come in for the hearing test,” said Dr. Cheri Ribbe, audiologist at the Boston VA Healthcare System where they started using PTM over two years ago. Her audiology clinic has seen over 500 Veterans take part in PTM — some who just came in for more information, and some who have gone on to higher levels of the PTM program.

The majority of people with tinnitus, about 80 percent, are not bothered by it; it doesn’t affect their sleep or their ability to concentrate. The small percentage of people who struggle with the noise in their head can be more prone to other debilitating mental health problems, like depression and anxiety. It is not yet understood why tinnitus affects people so differently.

After years of having few resources to offer tinnitus patients, Dr. Ribbe said she was excited to institute the PTM protocol. “It’s been gratifying and satisfying for us and the patient to know that we are offering something for them.”

Veteran account No.1August Firgau, an Army Veteran, has been living with tinnitus since 1951.

The main thing that helped me was when we set goals for ourselves in cognitive behavioral therapy. We talked about deep breathing, practicing deep breathing 3-4 times a week. And we practiced imagery, which helped me the most.

What I usually imagine — I like to do outdoor fishing. Finding a place, a very restful fishing spot, and enjoying taking in the different environmental sounds and the smells. Like birds chirping away, water rippling over stones, that can be very restful. The sounds of fish jumping out of the water and jumping back in again. It’s a very pleasant place to be in. You’re in deep nature and there’s no one there to interrupt you. This is what I like to imagine.

You want to just pretend it’s not there. I can go along in the daily things of life and not be aware of the tinnitus — not because it’s not there, because I can ignore it.

Sound Therapy

Once referred into the program, all patients with tinnitus are given a hearing exam. During the exam audiologists counsel patients regarding hearing loss, tinnitus and provide Veterans with educational materials.

Patients that need more guidance in finding a way to live with tinnitus are referred to group education workshops. Five sessions teach both audiologic and cognitive behavioral coping techniques.

Veterans are given a comprehensive self-help workbook with supporting materials, like worksheets and audio samples. Dr. Myers explained that instructors have the flexibility of using the provided handouts, slides, sound demonstration CDs, and DVDs to teach the workshops. She also noticed that group dynamics played an important role in the learning process.

“Patients love to talk about their tinnitus,” she said. “Which, as an audiologist, is what you don’t want your patient to do. You want to get their mind off the tinnitus. But in a group session, an audiologist is there to guide them through the process of how to manage their reactions to tinnitus.”

The use of sound is an important component of therapy for tinnitus. The self-help workbook offers many sample sounds and patient examples that Veterans can try out. They are taught to test three different sound management techniques: “soothing sounds” that offer relief from the stress they feel from tinnitus; “background sounds” that lessen awareness of the tinnitus; and “interesting sounds” that shift their focus away from the tinnitus.

Following up with management technique results in class has given the instructors a better understanding of the highly-individualized symptom they are trying to manage.

“The idea is to let them be open to sounds that they never would have even thought of,” explained Dr. Ribbe. She said that she never would have considered traffic noise as sound therapy, but for one Veteran who had grown up in the city those sounds brought him back to his childhood and pleasant memories.

Veteran account No.2Don Parrish had lived with a minor level of tinnitus since leaving the Air Force in 1969, but a few years ago he woke up in the middle of the night to a screaming in his ears.

Can you imagine a whistling in your ears constantly?

You can grow accustomed to anything, and that’s pretty much what I have done.

I wear a hearing device with masking noise in it 24/7 and that’s the most effective for me. I’ve got seven little iPods with more sounds on them; the one like a babbling brook is really helpful to me.

[The class] is great if you do it, but it’s really hard to work at it because you don’t see any immediate results. It took about six months of experimenting…at this point I can pretty much ignore it.

Coping techniques

Another technique covered in the workbook and class is cognitive behavioral therapy (CBT) exercises that address the negative reactions tinnitus can trigger.

“A lot of people with tinnitus develop emotional reactions to tinnitus,” said Dr. Caroline Schmidt, PTM author and Licensed Research Psychologist at the VA Connecticut Healthcare System. “Those could be lack of sleep, feeling anxious, frustration; some people relate the sound to a particularly traumatic event that happened.”

Whether the Veteran is already in contact with a mental health specialist or not, the PTM program introduces them to a series of CBT exercises that have proven effective in helping many tinnitus patients. Relaxation techniques, distraction by planning pleasant activities and changing how patients think about tinnitus are the three main techniques taught in the class.

After completing the workshops, many Veterans are able to come up with an action plan to manage their tinnitus through audiologic, cognitive behavioral techniques or some combination of the two. Providers follow up six weeks later to check on their progress and set up additional assistance for the few patients who need it.

In individual sessions, Dr. Schmidt said, “We review what we did with them during the classes. We review their individual response to those coping skills and help them really focus on problem solving those issues.”

Veteran account No.3John Foster was serving in World War II when he started hearing a ringing in his left ear. Living with the pain over the years, he lost sleep, gained weight and became a very angry person.

Once you find out it has no cure, the minute you do that, then you start to take steps to get better.

The program works, you’ve got to work the program though. What happens, as you work the program, you find different things that help you.

I bought a little bubbly fountain and I always liked the sound of water; that was kind of soothing. I found out that if I woke up I would hear the water, but I would focus more on the visualization and the breathing.

I picture myself walking on a beach, and I tried to think of the sun hitting me on the side of the face and I think about a breeze and I actually feel the breeze and then when I turn back, I feel the sun on the other side of my face and I actually see my footprints in the sand and by the time I do that I usually fall asleep.

You don’t want to visualize while you’re driving because you’ll get distracted. When I’m driving I do the deep breathing exercises and turn on the radio. You’ve got to put some effort into this; they give you all the techniques.

National protocol

In 2010, every VA medical facility audiology clinic received copies of the PTM clinical handbook, counseling guide and hundreds of patient-education workbooks.

The number of Veterans that complete the group education stage of PTM and go on to need individualized support is very small. So PTM’s hierarchical approach provides VA medical facilities with the most efficient means to educate Veterans and teach them self-management techniques.

“We’re always evolving, so PTM is not a static program,” said Dr. Henry. The patient-education workbook is already in its third edition and Dr. Henry has more clinical studies underway to expand PTM’s availability and effectiveness.

“We can’t cure it and nobody can cure it, so the next best thing is to learn self management techniques.”